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Introduction

==Introduction==
“Poverty and ill-health are inextricably linked. Poverty has many dimensions – material deprivation (food, shelter, sanitation, and safe drinking water), social exclusion, lack of education, unemployment, and low income – each of which “diminishes opportunities, limits choices, undermines hope, and threatens health.”  “Poverty has been associated with an increased risk of chronic disease, injury, poor infant development, a range of mental health issues (stress, anxiety, depression, and lack of self-esteem), and premature death. The burden of poverty falls most heavily on certain groups (women, children, ethnic and minority groups, and the disabled) and geographic regions.” -  are of special importance to the impoverished. As a group, impoverished people suffer worse health, which is demonstrated by disparities in health outcomes between the impoverished and other populations. This can be attributed to variation in the personal living conditions and social structures that affect the poor’s lives. For poor populations in particular, the social structure and socioeconomic factors also determine their particular health outcomes. “Socioeconomic factors, including education, poverty, income, income inequality, and occupation, are some of the strongest and most consistent predictors of health and mortality.”  Therefore, health disparities exist solely within impoverished populations, with these differences stemming from determinants of health in poverty. “The poor health of the poor, the social gradient 
in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies
and programmes, unfair economic arrangements, and bad politics. Together, the structural determinants and conditions
 of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries.”  Along with these social conditions, “Gender, education, occupation, income, ethnicity, and place of residence are all closely linked to people’s access to, experiences of, and benefits from health care.”   Social determinants of disease can be attributed to broad social forces such as racism, gender inequality, poverty, violence, and war.  Because health has been considered a fundamental human right, one author suggests the social determinants of health determine the determination of the distribution of human dignity. 

Definitions and Measurements

Social determinants of health in poverty reveal determining factors for inequalities in health. These inequalities are recognized by disparity. “ Disparity can be defined as a marked difference or inequality between two or more population groups defined on the basis of race or ethnicity, gender, educational level, or other criteria. Discussions of disparity in health generally focus on differences between two groups in a population.” Health is defined “as feeling sound, well, vigorous, and physically able to do things that most people ordinarily can do”. Measurements of health take several forms including, subjective health reports completed by individuals and surveys that measure physical impairment, vitality and well being, diagnosis of serious chronic disease, and expected life longeveity.

Determinants in Poverty

According to the WHO, social determinants of health include early child development, globalization, health systems, measurement and evidence, urbanization, employment conditions, social exclusion, priority public health conditions, and women and gender equality. - More generally, the WHO considers the circumstances of daily life and structural drivers, as dominant elements in determining health outcome differentials, as the social determinants. - Different exposures and vulnerabilities to disease and injury determined by social, occupational, and physical environments, result in more or less vulnerability to poor health. - Structural drivers, on the other hand, include stratification in society, biases and norms in society, economic and social policy, and governance. - These themes are condensed into a distinct structure of defining the social determinants of health in poverty. The World Health Organization’s Social Determinants Council recognized two distinct forms of social determinants for health- social position and socioeconomic and political context. The following divisions are adapted from World Health Organization’s Social Determinants Conceptual Framework for explaining and understanding social determinants of health.

Social Position

Poverty Gradient/ Severity of Poverty

Within the impoverished population exists a wide range of real income, from less than $2 USD a day, to the United States poverty threshold. - Within impoverished populations, being relatively versus absolutely impoverished can determine health outcomes, in their severity and type of ailment. According to the World Health Organization, “The poorest of the poor, around the world, have the worst health. Those at the bottom of the distribution of global and national wealth, those marginalized and excluded within countries, and countries themselves disadvantaged by historical exploitation and persistent inequity in global institutions of power and policy-making” suffer worse health outcomes.” “In rich and poor countries alike, ill-health follows a distinct social gradient: the lower an individual’s socioeconomic status, the worse their health.” As such, there is a way to distinguish between relative severity of poverty. “Poverty is defined, conceptualized, and measured within two broad frameworks. Absolute poverty is the severe deprivation of basic human needs such as food, safe drinking water and shelter, and is used as
a minimum standard below which no one should fall regardless of where they live. It is measured in relation to the ‘poverty line’ or the lowest amount of money needed to sustain human life. Relative poverty takes a more country specific approach and is defined as the inability to afford the goods, services, and activities needed to fully participate in a given society.”

Relative poverty still results in bad health outcomes because of the agency of the impoverished. According to the World Development Report, “Poor people everywhere have to choose and make many decisions about many things that richer people take for granted every day. When institutions are bad, so are people’s default choices—and “free to choose” becomes “forced to choose.” Therefore, many of these forced choices determine excess mortality. Severity of poverty results in different health outcomes because of the poor’s access and maintenance of certain essentials. Certain personal, household factors, such as living conditions, are more or less unstable in the lives of the impoverished and represent the determining factors for health amongst the poverty gradient. The following factors greatly impact the lives of the impoverished depending on the severity of poverty. Income can influence child and adult health through various household and environmental factors attributable to society. These factors prove challenging to individuals in poverty and are responsible for health deficits amongst the general impoverished population. Having sufficient access to a minimum amount of food, as well as nutritious and sanitary food play an important part in building health and reducing disease transmission. Access to sufficient amounts and quality water for drinking, bathing, and food preparation determines health and exposure to disease. Clothing and bedding prove important in that clothing must provide appropriate climatic protection and both clothes and bedding must be cleaned appropriately to prevent irritation, rashes, and parasitic life. Housing, including size, quality, ventilation, crowding, sanitation, and separation, prove paramount in determining health and spread of disease. Availability of fuel for adequate sterilizing of eating utensils and food and the preservation of food proves necessary to promote health. Transportation, providing access to medical care, shopping, and employment, proves absolutely essential. Hygienic and preventative care, including soap and insecticides, and vitamins and contraceptives, are necessary for maintaining health. Finally, sickness care proves absolutely essential in considerations of determining health outcomes. “Community-level variables- ecological setting- the ecological setting includes climate, soil, rainfall, temperature, altitude, and seasonality- are important for health. In rural subsistence societies, these variables can have strong influence on child survival by affecting the quantity and variety of food crops produced, the availability and quality of water, vector-borne disease transmission…. And Political economy, which Includes organization of production, physical infrastructure and political institutions.”

Gender

Gender can determine health inequity in general health and particular diseases, and is especially magnified in poverty. In impoverished populations, there is a pronounced differences in the types of illnesses and injuries men and women contract, as well as women suffer from gender inequality acutely in poverty. Socioeconomic inequality is often cited as the fundamental cause for differential health outcomes among men and women. ( [Adler and Ostrove, 1999], [Huisman et al., 2003] and [McDonough and Walters, 2001]). According to the World Health Organization, the health gap between the impoverished and other populations will only be closed if the lives of women are improved and gender inequalities are solved. Therefore, “Empowerment of women is key to achieving fair distribution of health.”

Gender gaps in health have been recognized by mortality and morbidity rates, as well as prevalence of particular diseases. “The rate at which girls and women die relative to men is higher in low- and middle-income countries than in high-income countries. To quantify this excess female mortality (“missing” girls and women)… this Report estimated the number of excess female deaths at every age and for every country [during three time intervals]… Excess female deaths in a given year represent women who would not have died in the previous year if they had lived in a high-income country, after accounting for the overall health environment of the country they live in. Globally, excess female mortality after birth and “missing” girls at birth account every year for an estimated 3.9 million women below the age of 60. About two-fifths of them are never born, one-fifth goes missing in infancy and childhood, and the remaining two-fifths do so between the ages of 15 and 59”. “Globally, girls missing at birth and deaths from excess female mortality after birth add up to 6 million women a year, 3.9 million below the age of 60. Of the 6 million, one-fifth is never born, one-tenth dies in early childhood, one- fifth in the reproductive years, and two-fifths at older ages. These excess deaths have persisted throughout the decades, and some even increased. in the countries hardest hit by the HIV/AIDS epidemic, things got worse. In South Africa, excess female deaths increased from (virtually) zero between the ages of 10 and 50 in 1990 to 74,000 every year by 2008.” In respect to differentials in particular diseases that are likely to determine health in poor women, poor women have more heart disease, diabetes, cancer, and infant mortality. Poor women also have significant comorbidity, or existence of two ailments, such as psychiatric disorders with psychoactive substance use. They are also at greater risk for contracting endemic conditions like tuberculosis, diabetes, and heart disease. “Low income women in urban areas are more likely to have unplanned pregnancies or sexually transmitted diseases”. “Studies in Denmark, England, Wales, Columbia, Finland, and for many states and ethnic groups in the United States, show that a woman’s risk for cervical cancer increases as her socio-demographic status goes down”. This excess mortality and sickness can be attributed to household and socioeconomic reasons. First, Women have differential health patterns because of inequality between and within households. Determinants of health for impoverished women at the household level concern home life, stress, and distribution of resources. “The way in which resources such as money, food, and emotional warmth are exchanged in the household influences psychosocial health, nutritional well-being, access to health services, and the expression of violence. Resource exchange mediates the effects of geopolitical, cultural, and household patterns of equity and inequality on health status and outcomes. Health-related mediators of inequality and equity include health behaviours; access to and use of health services; stressors; and psychosocial resources and strategies including social ties, coping and spirituality”. “Missing girls at birth arise from household discrimination. Any solution to this problem has to come through household decision-making processes. These processes can be manipulated through markets and institutions, but markets and institutions alone will not do the trick. After birth, although discrimination remains salient in some countries, in many other countries high female mortality reflects poorly performing institutions of service delivery.”

With respect to socioeconomic factors, rather than overt discrimination playing a large role, poor institutions of public health and services can cause worse health in women. ”Gender inequities influence health through, among other routes, discriminatory feeding patterns, violence against women, lack of decision-making power, and unfair divisions of work, leisure, and possibilities of improving one’s life.” “Determinants of women's health in the geopolitical environment include country-specific history and geography, policies and services, legal rights, organizations and institutions, and structures that shape gender and economic inequality. Culture, norms and sanctions at the country and community level, and socio-demographic characteristics at the individual level, influence women's productive and reproductive roles in the household and workplace. Social capital, roles, psychosocial stresses and resources, health services, and behaviors mediate social, economic and cultural effects on health outcomes.” Also, Women facing financial difficulty are more likely to report chronic conditions of health, which occurs often in the lives of the impoverished. Socioeconomic inequality is often cited as the fundamental cause for differential health outcomes among men and women. ( [Adler and Ostrove, 1999], [Huisman et al., 2003] and [McDonough and Walters, 2001]). Therefore, many would interpret that women’s health status has improved with improving socioeconomic status among women. Also, social scientists hypothesize that several social factors attributed to gender inequality could be responsible for differentials in reported health. First, women might report higher levels of health problems as a result of differential exposure or reduced access to material and social factors that foster health and well-being (Arber & Cooper, 1999). Second, women might report higher health problems because of differential vulnerability to material, behavioral, and psychosocial factors that foster health (McDonough & Walters, 2001).” Differences in economic independence and the ramifications of inequality explain the health disadvantage of females reported among older adults in India, according to one study. “The poorer health and lower healthcare utilization noted among older women, compared with men in India, can be largely explained by gender differentials in socioeconomic status and consequent financial empowerment.”

Poverty and ill-health are inextricably linked. Poverty has many dimensions – material deprivation (food, shelter, sanitation, and safe drinking water), social exclusion, lack of education, unemployment, and low income – each of which “diminishes opportunities, limits choices, undermines hope, and threatens health.” “Poverty has been associated with an increased risk of chronic disease, injury, poor infant development, a range of mental health issues (stress, anxiety, depression, and lack of self-esteem), and premature death. The burden of poverty falls most heavily on certain groups (women, children, ethnic and minority groups, and the disabled) and geographic regions.” - are of special importance to the impoverished. As a group, impoverished people suffer worse health, which is demonstrated by disparities in health outcomes between the impoverished and other populations. This can be attributed to variation in the personal living conditions and social structures that affect the poor’s lives. For poor populations in particular, the social structure and socioeconomic factors also determine their particular health outcomes. “Socioeconomic factors, including education, poverty, income, income inequality, and occupation, are some of the strongest and most consistent predictors of health and mortality.” Therefore, health disparities exist solely within impoverished populations, with these differences stemming from determinants of health in poverty. “The poor health of the poor, the social gradient 
in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies
and programmes, unfair economic arrangements, and bad politics. Together, the structural determinants and conditions
 of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries.” Because health has been considered a fundamental human right, one author suggests the social determinants of health determine the determination of the distribution of human dignity.